Download or read book Guide to Documentation Requirements in the Medical Record written by Maryland Medical Record Association. Ad hoc Committee on Documentation and published by . This book was released on 1977 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Complete Guide to Documentation written by Lippincott Williams & Wilkins and published by Lippincott Williams & Wilkins. This book was released on 2008 with total page 454 pages. Available in PDF, EPUB and Kindle. Book excerpt: Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management. Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.
Download or read book Guide to Documentation Requirements in the Medical Record written by Maryland Medical Record Association. Ad Hoc Committee on Documentation and published by . This book was released on 1975 with total page 171 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Guide to Clinical Documentation written by Debra D Sullivan and published by F.A. Davis. This book was released on 2018-07-25 with total page 417 pages. Available in PDF, EPUB and Kindle. Book excerpt: Understand the when, why, and how! Here’s your guide to developing the skills you need to master the increasing complex challenges of documenting patient care. Step by step, a straightforward ‘how-to’ approach teaches you how to write SOAP notes, document patient care in office and hospital settings, and write prescriptions. You’ll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand.
Download or read book Electronic Medical Records written by Jerome H. Carter and published by ACP Press. This book was released on 2001 with total page 478 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical Infomation Systems are increasingly important in Medical Practice. This work is a two-part book detailing the importance, selection and implementation of information systems in the health care setting. Volume One discusses the technical, organizational, clinical and administrative issues pertaining to EMR implementation. Highlighted topics include: infrastructure of the electronic patient records for administrators and clinicians, understanding processes and outcomes, and preparing for an EMR. The second workbook is filled with sample charts and questions, guiding the reader through the actual EMR implementation process.
Download or read book Guide to Clinical Documentation written by Debra Sullivan and published by F.A. Davis. This book was released on 2011-12-22 with total page 301 pages. Available in PDF, EPUB and Kindle. Book excerpt: Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.
Download or read book Clinical Documentation Reference Guide First Edition written by AAPC and published by AAPC. This book was released on 2020-03-12 with total page 13 pages. Available in PDF, EPUB and Kindle. Book excerpt: It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.
Download or read book Nursing Documentation Made Incredibly Easy written by Kate Stout and published by Lippincott Williams & Wilkins. This book was released on 2018-06-05 with total page 487 pages. Available in PDF, EPUB and Kindle. Book excerpt: Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more. Whether you are a nursing student or a new or experienced nurse, this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely, accurate, and watertight. Let the experts walk you through up-to-date best practices for nursing documentation, with: NEW and updated, fully illustrated content in quick-read, bulleted format NEWdiscussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices Easy-to-read, easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations, while addressing the different styles of charting Outlines the Do's and Don’ts of charting – a common sense approach that addresses a wide range of topics, including: Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation Documenting the patient’s health history and physical examination The Joint Commission standards for assessment Patient rights and safety Care plan guidelines Enhancing documentation Avoiding legal problems Documenting procedures Documentation practices in a variety of settings—acute care, home healthcare, and long-term care Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior Special features include: Just the facts – a quick summary of each chapter’s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans “Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.
Download or read book 2022 Hospital Compliance Assessment Workbook written by Joint Commission Resources and published by . This book was released on 2021-12-30 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Pocket Guide to Therapy Documentation written by HCPro and published by HC Pro, Inc.. This book was released on 2008 with total page 108 pages. Available in PDF, EPUB and Kindle. Book excerpt: Put documentation tips in the palm of your hand with documentation pocket guides made just for therapists! Proper documentation is vital to reimbursement and patient care in the therapy setting. Improper documentation can lead to a host of problems including denials, decreased reimbursement and lawsuits. Unfortunately, therapists don't receive formal training on documentation and are often left to decipher the confusing requirements set forth by Medicare, Medicaid, and managed care companies, alone. A quick, affordable and convenient tool to address therapy documentation The Pocket Guide to Therapy Documentation offers documentation tips and advice in a convenient and handy format. You'll keep this resource close at hand to ensure complete and accurate patient records. Ensure proper documentation and save time with these benefits: Condensed information and easy-to-read bulleted lists, charts, and tabs for quick reference Fast access to reimbursement and coding information Review documentation requirements in less time for all patient encounters including: Initial examination Evaluation Prognosis Diagnosis Reexamination Discharge Tests and measures Therapy managers in Long-Term Care, home health, and hospital settings will want to purchase one for each Occupational Therapist, Speech Language Pathologist, and Physical Therapist in their facility.
Download or read book Documentation Improvement Handbook for the Medical Staff written by Jean S. Clark and published by Hcpro Incorporated. This book was released on 2003 with total page 22 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Medical Record Auditor written by Deborah J. Grider and published by American Medical Association Press. This book was released on 2015 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Providing in-depth guidance for proper review of medical documentation in today's changing medical environment, this fourth edition of the Medical Record Auditor is full of new content. New topics include electronic health records (EHR), ICD-10 coding, Health Information Management and many other issues essential for maintaining compliance. Learn critical auditing fundamentals, read dozens of case studies, use the checkpoint exercises to test your knowledge, and download actual audit forms to help improve your process. Features and Benefits - New content addresses EHRs, ICD-10 coding and more - Downloadable forms. One copy of each audit form is included, but all forms are downloadable from website - Case studies. Ten different specialties are featured with more than 80 total case studies - Checkpoint exercises. Test your knowledge to confirm comprehension of new content
Download or read book The Complete Legal Guide to Healthcare Records Management written by Cherilyn G. Murer and published by McGraw-Hill Companies. This book was released on 2000 with total page 808 pages. Available in PDF, EPUB and Kindle. Book excerpt: While much has changed in the delivery of healthcare in this country, what has not changed is the importance of maintaining and managing medical records. All healthcare organizations must keep complete medical records to comply with Federal and state laws, to minimize exposure to malpractice liability and to ensure that quality care is given to patients.With more systems crossing state lines and an increase in centralized medical records departments, The Complete Legal Guide to Healthcare Records Management becomes a valuable resource to the professional who handles records from multiple geographic locations. Users of this resource will be in a position to maintain or improve their records management systems and to protect themselves from regulatory compliance violations and malpractice liability.The Complete Legal Guide to Healthcare Records Management is an all-in-one resource and reference for healthcare professionals in a variety of settings. The comprehensive state-by-state format allows organizations who deliver care in diverse geographic locations to understand and account for variations in state requirements on record keeping.Topics covered in The Complete Legal Guide to Healthcare Records Management: -- Records defined -- general discussion and definitions of Federal and state laws -- Ownership issues of medical records -- general ownership, physician/provider conflict -- Records to keep -- Why must you keep records? -- Time requirement for record-keeping -- The electronic record and special problems with advancing technology -- Storing medical records -- Correcting medical records -- Disclosure of records -- such as drug and alcohol abuserecords, communicable disease information -- Dealing with court orders and subpoenas -- Participation in Medical Research -- Disposal of medical records -- Healthcare business records -- what are they and do you keep them?The Complete Legal Guide to Healthcare Records Management is a must-have for anyone in the healthcare industry who comes in contact with healthcare records!
Download or read book Registries for Evaluating Patient Outcomes written by Agency for Healthcare Research and Quality/AHRQ and published by Government Printing Office. This book was released on 2014-04-01 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Download or read book The Clinical Documentation Improvement Specialist s Guide to ICD 10 written by Glenn Krauss and published by HC Pro, Inc.. This book was released on 2011-03 with total page 163 pages. Available in PDF, EPUB and Kindle. Book excerpt: Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in
Download or read book Electronic Health Records written by Jerome H. Carter and published by ACP Press. This book was released on 2008 with total page 554 pages. Available in PDF, EPUB and Kindle. Book excerpt: Resource added for the Health Information Technology program 105301.
Download or read book Chart Smart written by and published by Springhouse Corporation. This book was released on 2011 with total page 516 pages. Available in PDF, EPUB and Kindle. Book excerpt: Chart Smart: the A-to-Z Guide to Better Nursing Documentation tells nurses exactly what to document in virtually every type of situation they may encounter on the job, no matter where they practice--hospital, medical office, outpatient, rehabilitation facility, long-term care facility, or home. This portable handbook has nearly 300 entries that cover documentation required for common diseases, major emergencies, complex procedures, and difficult situations involving patients, families, other health care team members, and supervisors. In addition to patient care, this book also covers documenta
